University of Bohol

College of Nursing
City of Tagbilaran

Family Health Assessment Form

Family Surname: MEJIA Name of Family Head: MICHELLE

House Number: 0328 Purok Number: NONE
Purok Name: KARAW AN Barangay: DAMPAS Municipality: TAGBILARAN CITY
Source of Information: MICHELLE M MEJIA Relation : MOTHER
Data Gathered By: MARIA RIZA MAE M MEJIA Date: SEPTEMBER 6, 2020

A.Household Members:

No. Family Sex Ag Civil Relation Religi Educational Occupation

e Status to Head on Attainment
Members

1 MICHELLE MEJIA F 50 Marrie MOTHER Rom COLLEGE NURSE

d an GRADUAT
Cath E
olic
2 MARIA RIZA MAE F 23 SINGLE DAUGTHE Rom COLLEGE STUDENT
MEJIA R an GRADUAT
Cath E
olic
3 MARIA CHARMIN M 21 SINGLE DAUGHTE Rom High STUDENT
MEJIA R an School
Cath Graduate
olic
4 ALBERT MESHAEL M 15 Single SON Rom COLLEGE STUDENT
MANZANILLA an STUDENT
Cath
olic
B. Family Characteristics:
Type of family structure

() Nuclear Family () Dyad Family () Compound Family

() Extended Family () Blended Family () Cohabiting Family (✔) Single Parent Family

Name Age Relationship Location of Occupation/ Frequency Means of

to Head member Work of Contacts communication

Family Mobility
Length of time of current address:__11 YEARS_________________________________________
Address of Previous Residence: _NONE, _______________________________________________
Frequency of geographic move: __1________________________________________

Family Dynamics:
Emotional Bonding of Family Members__Closely-knit family
bonding_______________________________________
Distribution of Authority and Power _Agreed upon by both the husband and
wife___________________________________________
How members communicate_verbally & social media

Dominant Members in terms of decision making __________________________________

() Husband (✔) Wife () Adult Children () Others (specify) _______________

How are problems solved? _honest and open communication

___________________________________________________
How is conflict handled? _face-to-face_____________________________________________________
Division of labor _Tasks and chores equally distributed among members of the
family____________________________________________________________

C. Socio Economic and Cultural Characteristics

Family Social Integration:
Languages or Dialect(s) Spoken :
(✔) Visayan/ Cebuano (✔) Tagalog (✔) English () Others (specify) ____________________

Literacy (Ability to read and Write in language(s)

(✔) Yes () No

Degree of social network with friends, neighbors and other relative _Often uses social media to connect
with other family members, friends and relatives____________________

Network with religious organizations (name of organization of which the family members are involve)

______none_________________________________________________________________
Network with Social Organizations (name of the organizations of which family members are involve)

____none__________

Educational: experience_College
graduate________________________________________________________

Work Experience ___________________________________________________________

Adequacy of Financial Resources:

Monthly Family Income source
Husband: _______BUSINESS____________ Wife______________ Others (specify) SON- work
_____________

Total Monthly Family Income: (please check)

() below P5000 () P21, 000-P30, 000

() P6, 000- P10, 000 () P30, 000-P40, 000
()P11, 000-P15,000 () P40,000- P50, 000
(✔) P16, 000- P20, 000 ()Above P50,000

Identify and rank according to priority family needs:

1. Bonding with Family &time for God
2. Food
3. Water
4. Internet
5. communication

Leisure Time (Name some leisure time activities you are interested at)__eating, Watching Movies,
Cleaning house hold chores and , Chatting on messenger,____________________

___________________________________.

D. Cultural Influences: Values/Attitudes/Beliefs about

Spirituality Believing that the prayer can heal, prayer is important
_____________________________________________________
Rituals (Holidays and Celebrations) _______fiesta, birthday, Christmas, new year,
________________________________
Health ____none__________________________________________________________
Folk diseases _____none____________________________________________________
Traditional Healer _____none________________________________________________

E. Family and Environment

1. Home
a. Ownership- (✔) owned () rented () rent free

b. Construction Material
() light ✔ mixed () Strong

c. Number of bedrooms:_4__

d. Lighting facility
(✔) Electricity () Kerosene () Others (specify)_________________

e. General sanitary condition __Clean & Maintained____________________________________

2. Drinking and Water supply

 a. source
Level 1 – (point source)

() shallow or deep well. improved Dug Well

() Developed spring ✔rain tank

Level 2 (communal faucet)

✔ waterworks system (✔) Water refilling station

b. Distance from the house: highway _motorcycle for 5 minutes count to water refilling
station_______________________________________

c. Storage:
() None (direct from the faucet)
✔ Large covered container with faucet
() Large uncovered container with faucet
() Others (specify)___________________

3. Kitchen

a. Cooking facility used:

() electric stove (✔) Gas stove
(✔) firewood /Charcoal () Others (specify)________________

b. Food storage:
(✔) Covered () Uncovered (✔) Refrigerator
(✔) container with cover
() container without cover

c. sanitary condition:__Clean & well

maintained__________________________________________________

d. Drainage facility of kitchen:

() Open drainage
✔ blind drainage
None

4. Waste Disposal

a. Garbage container

✔ covered () Open () none

b. Method of disposal

() Hog feeding ✔ open burning () Open dumping

(✔) garbage collection () burying in pit (✔)Composting

() Others (specify) _________________________

c. Excreta disposal:
✔Tank flush toilets (connected to septic tanks with sewerage system)

() Pour-Flush Latrine

() Ventilated-improved pit latrine

 () Overhung latrine

() Antipolo toilet

() Pit latrine

() box and can privy

() Shared

() none

d. Distance from the house ____7 meters______

e. Sanitary condition (describe briefly the state of cleanliness) ___well ventilated and good
disposal, properly manage about cleanliness of the area____________________

5. Domestic animals/common household pets

Kind Number Place kept

2 Outside the house

Dog

Many Outside the house

Fish
7 Inside the house

Spider (Tarantula)

6. Pest and Vermin Control: Presence of breeding sites of insects, rodents, etc.

() Yes; specifically: ____________________________________________

✔ No

7. Presence of Accident Hazards: ✔ Yes () No

If yes, Specify_______________________

() Broken parts of the house () Medicines (not kept)

() Sharp Objects (not kept) ✔ Broken glasses

() stray animals

F. Family Neighborhood

a. Location: ✔urban rural () subdivision () slum area

 b. Type: ✔ residential () Semi Commercial

c. Safety: () traffic patterns (✔) Lighting () security ( private. /police)

✔ pedestrian lanes (✔) walking pathways

d. Population Density (crowding)

(✔) congested non congested

e. Sources of pollution

(✔) air ✔ water () Soil () noise

f. Social and health facilities available

(✔) Barangay Health Station () Rural Health Units

✔ Private Clinics/Hospitals ✔ Barangay Hal

✔ Chapel () Senior Citizen’s Hall

✔ basketball court ✔ Purok Kiosk

g. Communication facilities of the family

✔ cellphone

() landline Telephone

(✔) Computer/Laptop connected to internet

h. Transportation Facilities:

() Public Utility vehicle

(✔) owned private cars

✔ own motorcycles

() rented vehicles

G. Family Health/Behavior

a. Activities of daily living (How the family spends a typical day)___Clean the surrounding, house
hold chores, Cooking, Preparing for meals. _________________

_________________________________________________________________.

b. Health History:

1. Pregnancy: First delivery normal, Third delivery

Normal_____________________________________________________________
 2. Illness:
Hypertension_______________________________________________________________
___

3. Death within the past 5 years: ✔ Yes () No

4. Health Attendance: (How Often)

() every month () once a year

✔ as the need arises () never () Others

(specify)___________________

c. Self -Care Activities (name family’s related activities) __mother- mesicine maintenance for high
blood pressure losartan , father- medicine maintenance for hypertension
______________________________

d. Risks Factor assessment for specific lifestyle diseases:

✔ Hypertension () Physical inactivity

() Sedentary lifestyle () Cigarette/tobacco smoking

() Elevated lipids/cholesterol () Alcohol drinking

() Obesity () diabetes mellitus

() inadequate fiber intake () Stress

() poor diet () Substance abuse

() others (specify)_______________________________

e. Present Health Status:

A. Father/Head of the family: ________________________________________________

Vital Signs: T-_____________ BP______________ HR___________ RR _______________

Physical complaints: _________ ________________________________________________

B. Mother/ Wife: MICHELLE M. MEJIA

___________________________________________________________

Vital Signs: T-_____36.4_____ BP_____120/80_________ HR____90_______ RR

_____20_________

Physical
complaints:________________HYPERTENSION___________________________________

C. Other members: ___MARIA RIZA MAE MEJIA

_________________________________________________________

Vital Signs: T-_______36______ BP______110/70________ HR______74______ RR

______21_________

Physical complaints:
_______________NONE__________________________________________
f. Common Illness encountered and management done

Age Illness Management

0-1

1-3

3-6

6-7

7-12

13-18

19-25

26-35

36-45

46-50 Hypertension Check up and maintenance

of medication
51-55

56-60
60-up

g. Health Care Resources

a. Where do you consult for health related problems?

() “Manghihilot”/ Albularyo () BHW’s

✔ Physician/Doctor () RHU (MHO, PHN, PHM)

() Alternative treatment Clinics () Others (specify) _________________

b. For Problems other than health, whom do you consult?

✔ family member () relatives

() Friends () Priest

() Barangay Officials (✔) Health workers

() Others (specify) ____________________________________

c. Immunization status of children:
Are the children immunized? ✔ Yes () No

() Yes, if yes, check immunization received

() BCG ✔ Hep B vaccine
() OPV () AMV
✔ Pentavalent vaccine () MMR
(DPT, Hep B. Hib)
d. Adequacy of:

1. Rest and sleep: ✔ Yes () No

If No, Why? ___________________________________________

2. Exercise and Physical Activity: ✔Yes () No

If No, Why? ___________________________________________

3. Stress Management Activity/relaxation: ✔ Yes () No

If No, why? ___________________________________________

If Yes, How often? () Daily ✔ once a week

() Three times a week () once a month

() Never () Others (specify)_______